1. May 18, 2016 Dawn Traver, M.Ed. Director, Waiver Operations Division of Developmental Services Waiver Redesign Changes and Opportunities for People Enrolled in the Day Support, DD or ID Waivers

2. Slide 2 Today’s Discussion 1. Service Planning Process 2. Role of the Supports Intensity Scale ® Assessment 3. Support Coordination/Case Management 4. New Services 5. Transfers Between Waiver 6. How to Stay Informed

3. Slide 3 Proposed Integrated I/DD Waiver Redesign Day Support Waiver Building Independence Waiver For adults (18+) able to live independently in the community. Individuals own, lease, or control their own living arrangements and supports with the option of non-waiver-funded rent subsidies. DD Waiver Family & Individual Supports Waiver For individuals living with their families, friends, or in their own homes, including supports for those with some medical or behavioral needs. Available to both children and adults. ID Waiver Community Living Waiver 24/7 services and supports for individuals with complex medical and/or behavioral support needs through licensed services. Includes residential supports and a full array of medical, behavioral, and non-medical supports. Available to adults and some children.

4. Slide 4 Service Planning Process

5. Slide 5 5 Building Blocks of DD System Employment and Alternate Day Options Including Volunteering & Recreation Self-Directed Options & Services that build links with others Residential Options-that access similar housing as others REACH Crisis Support Options— everywhere Medical and Behavioral Support Options- connecting to primary care Additional Options- professional Our opportunities are impacted by how strong or weak our links are to others in the greater community in which we live. Proposed

6. Slide 6 The Person-Centered Plan The use of the DBHDS developed Person-Centered Plan format will be phased in across the amended waivers – PC ISP Part I: Essential Information – PC ISP Part II: Personal Profile – PC ISP Part III: Shared Planning – PC ISP Part IV: Agreements – PC ISP Part V: Plan for Supports http://www.dbhds.virginia.gov/professionals-and- service-providers/developmental-disability-services-for- providers/provider-development

7. Slide 7 Supports Intensity Scale® Since 2009, the SIS® and the Person-Centered Plan have been used in tandem for those in the ID and DS waivers to – assess the individual – document the agreed-upon desired outcomes and means to achieving those outcomes – document what is important to and important for the individual The SIS® will now be used for person-centered planning and level assignment in the amended waivers

8. Slide 8 Supports Intensity Scale® More information at: http://www.dbhds.virginia.gov/professionals-and- service-providers/developmental-disability-services-for- providers/waiver-services

9. Slide 9 Integrated Supports

10. Slide 10 Integrated Supports

11. Slide 11 Role of the Supports Intensity Scale® Assessment

12. Slide 12 Supports Intensity Scale® Sections of the SIS ® – Support Needs home living, community living, lifelong learning, employment, health and safety, social activities – Protection and Advocacy – Exceptional Medical and Behavioral Responses to certain “Exceptional Medical/Behavioral” questions may trigger the completion of the “Supplemental Questions” Responses to certain Supplemental Questions may trigger the “Verification” process

13. Slide 13 Supports Intensity Scale® (cont’d) The results of the SIS, Supplemental Questions, and Verification process determine the individual’s level of supports. All individuals receiving services through the amended waivers must have a SIS ®. Ascend is the DBHDS contractor conducting SISs for individuals across the state. As of the end of April, 6,746 have been completed. – Prioritizing those individuals participating in services that have reimbursement rates dependent on their level. 2,132 top priority individuals remain to be completed.

14. Slide 14 Relationship of Individual Levels to Reimbursement Tiers Low Low to Mod Mod + some behavior challen- ges Mod to high Max Signi- ficant due to medical challen- ges Signi- ficant due to behavior challen- ges Level 1 Level 2 Level 3 Level 4 Level 5 Level 6 Level 7

15. Slide 15 Supports Needs Levels/Tiers Projections Levels and Tiers

16. Slide 16 Fundamental to the Amended Waivers Individual is assessed using the Supports Intensity Scale® Assessment results in supports level assignment (1 – 7) Individual selects services/ hours up to existing limits DBHDS Pre- authorization staff ensure appropriate service level for individual’s needs Some rates are based upon a four tiered reimbursement model to support higher staffing patterns for individuals with greater assessed intensity of need

17. Slide 17 Support Coordination/Case Management

18. Slide 18 Support Coordination/Case Management CSB will be the single point of entry Individuals may choose to receive support coordination/case management (SC/CM) from a CSB other than the one in whose jurisdiction they reside Individuals with a developmental disability other than ID may choose to receive SC/CM from a private SC/CM provider that has a contract with that CSB

19. Slide 19 New Services

20. Slide 20 Employment & Day Options* Building Independence Family & Individual Community Living Individual Supported Employment Group Supported Employment Workplace Assistance Services Community Engagement Community Coaching Group Day Services Employment & Day Options *Currently proposed that Employment and Day Options cannot exceed 66 hours per week combined.

21. Slide 21 Employment & Day Options: Community Engagement New Service! Allowable activities include but are not limited to: Activities and events in the community Community, educational or cultural activities and events Unpaid work experiences (volunteer opportunities) Employment readiness activities including discovery of interests, abilities and skills Maintaining contact with family and friends Gives flexibility to various day activities Provides a wide variety of opportunities to facilitate and build relationships and natural supports in the community, while utilizing the community as a learning environment. These activities are conducted at naturally occurring times and in a variety of natural settings in which the individual actively interacts with persons without disabilities (other than those paid to support the individual).

22. Slide 22 Employment & Day Options: Community Coaching New Service! Allowable activities include but are not limited to: Skill building through the implementation and participation in community activities and opportunities such as: Activities and public events in the community Community educational activities and events Utilization of public transportation Skill building and support in positive behavior, relationship building and social skills. Support with self-management, eating, and personal care needs of the individual while in the community Assuring the individual’s safety through 1:1 supervision in a variety of community settings A service designed for individuals who need one to one support in order build a specific skill or set of skills to address a particular barrier(s) preventing a person from participating in activities of Community Engagement.

23. Slide 23 Employment & Day Options: Workplace Assistance New Service! Allowable activities include but are not limited to: Skill building and supports around non-work skills necessary to maintain employment Skill building and supports in the home, community or workplace of employment maintenance related skills Supports to make and strengthen community connections Safety supports to ensure the individual’s health and safety. Workplace Assistance services are supports provided to someone who has completed job development and completed or nearly completed and job placement training (i.e., supported employment) but requires more than typical job coach services to maintain stabilization in their employment.

24. Slide 24 Residential Options Building Independence Family & Individual Community Living Independent Living Supports Shared Living Supported Living In-Home Support Services Sponsored Residential Group Home Residential Residential Options

25. Slide 25 Residential Options: Independent Living Supports New Service! A service provided to adults (18+) that offers skill building and support to secure self-sustaining, independent living in the community and/or may provide the support necessary to maintain those skills. Typically lives alone or with roommates in own home/apartment. The allowable activities include but are not limited to: Skill-building and support to promote community inclusion Increasing social abilities and maintaining relationships Increasing or maintaining health, safety and fitness Improving decision-making and self-determination Promoting meaningful community involvement Developing and supporting with daily needs

26. Slide 26 Residential Options: Shared Living New Service! Medicaid payment for a portion of the total cost of rent, food, and utilities that can be reasonably attributed to a person who has no legal responsibility to support the individual and resides in the same household as the individual. In Shared Living: Match is based on individual choice and supports are arranged through a person-centered process. The live-in companion has no responsibility for skill-building or medical services. The live-in companion must complete and pass background checks and successfully meet training requirements defined in the individual's person-centered plan. The coordinating agency must ensure that there is a back-up plan in the event that the live-in companion is unable to provide supports. Shared Living location cannot be in a provider-run home, the live-in companion’s home, or any other arrangement where the individual is not directly responsible for that residence.

27. Slide 27 Crisis Support Options Building Independence Family & Individual Community Living Community-Based Crisis Supports Center-Based Crisis Supports Crisis Support Services Crisis Support Options

28. Slide 28 Crisis Support Options: Community-Based Crisis Supports New Service! The allowable activities include but are not limited to: Psychiatric, neuropsychiatry, and psychological assessment, and other assessments and stabilization techniques; Medication management and monitoring; Behavior assessment and positive behavior support; Intensive care coordination with other agencies and providers to maintain community placement of the individual; Training of family members and other caregivers; Assisting with skill building as related to the behavior creating the crisis. Services to individuals experiencing crisis events which put them at risk for homelessness, incarceration, hospitalization, and/or danger to self or others. Supports are provided in the individual’s home and community setting. Crisis staff work directly with and assist the individual and their current support provider or family. These services provide temporary intensive services and supports that avert emergency psychiatric hospitalization or institutional placement or prevent other out-of-home placement.

29. Slide 29 Crisis Support Options: Center-Based Crisis Supports New Service! The allowable activities include but are not limited to: Psychiatric, neuropsychiatry, and psychological assessment, and other assessments and stabilization techniques; Medication management and monitoring; Behavior assessment and positive behavior support; Intensive care coordination with other to maintain community placement of the individual; Training of family members and other caregivers Assisting with skill building in the Crisis Therapeutic Home as related to the behavior creating the crisis; Supervision of the individual in crisis to ensure his or her safety and that of others in the environment and fitness. Long term crisis prevention and stabilization in a residential setting (Crisis Therapeutic Home) through utilization of assessments, close monitoring, and a therapeutic milieu. Services are provided through planned and emergency admissions.

30. Slide 30 Crisis Support Options: Crisis Support Services New Service! The allowable activities include but are not limited to: Crisis Prevention Crisis Intervention Crisis Stabilization Intensive supports by appropriately trained staff in the area of crisis prevention, crisis intervention, and crisis stabilization to an individual who may experience an episodic behavioral or psychiatric crisis in the community which has the potential to jeopardize their current community living situation. Designed to stabilize the individual and strengthen the current living situation so the individual can be supported in the community during and beyond the crisis period.

31. Slide 31 Medical & Behavioral Options Building Independence Family & Individual Community Living Skilled Nursing Private Duty Nursing Therapeutic Consultation Personal Emergency Response System (PERS) Medical & Behavioral Options

32. Slide 32 Medical and Behavioral Options: Private Duty Nursing New Service! The allowable activities include but are not limited to: Skill-building and support to promote community inclusion Monitoring of an individual's medical status; Administering medications and other medical treatment; or Training, consultation, nurse delegation or oversight of family members, staff, and other persons responsible for carrying out an individual's support plan Individual and continuous care (in contrast to part-time or intermittent care) by a RN or LPN for individuals with a serious medical condition and/or complex health care need, certified by a physician as medically necessary to enable the individual to remain at home, rather than in a hospital, nursing facility or ICF-IID.

33. Slide 33 Additional Options Building Independence Family & Individual Community Living Assistive Technology Benefits Planning Services† Community Guide† Electronic Home-Based Services Environmental Modifications Non-Medical Transportation† Transition Services Additional Options † Available 7/1/17

34. Slide 34 Unit Additional Options: Electronic Home-Based Services (EHBS) Examples include: Electronic devices that verbally prompt the individual to turn off the stove or lock the front door Sensors that provide a family member or provider with information about the individual's movements around his/her living area. Ongoing electronic monitoring through off-site live video feed, audio feed, motion sensing devices and 2-way communication with the individual being monitored Goods and services based on Smart Home© technology. This includes purchases of electronic devices, software, services, and supplies not otherwise provided through this waiver or through the State Plan, that would allow individuals to access technology that can be used in the individual’s residence to support greater independence and self-determination. New Service!

35. Slide 35 New (and Old) Services Reimbursement Rates http://www.dbhds.virginia.gov/professionals-and- service-providers/developmental-disability-services-for- providers/my-life-my-community-waiver-redesign

36. Slide 36 Transfers Between Waivers

37. Slide 37 Reserve Slots Reserve slots are managed by DBHDS. Reserve slots support emergencies and movement between the waivers. At least 40 reserve slots will be available to support movement. Any reserve slots unused near the end of the fiscal year will be allocated.

38. Slide 38 http://www.dbhds.virginia.gov/individuals-and- families/developmental-disabilities/my-life-my- community Updates at My Life My Community at DBHDS.virginia.gov For questions, call toll-free: 1-844-603-9248 (1-844-603-WAIV) Interactive website available later in May Updates at My Life My Community at DBHDS.virginia.gov For questions, call toll-free: 1-844-603-9248 (1-844-603-WAIV) Interactive website available later in May My Life, My Community

39. Slide 39 Thank you!